Overcoming Opioid-Induced Oversedation: More Than Meets the Eye ANCC National Magnet Conference 2013 Jeannine M. Brant, PhD, APRN, AOCN Lisa Peterson, RN-BC, BSN Health Care, Education and Research www.billingsclinic.com Billings Clinic Largest healthcare organization in the region 1 st Redesignation for Magnet in 2012 >600 nurses Safest hospital in US according to Consumer Reports 1
Amanda 16 year old female 60% curvature of the spine Admitted to the hospital for spinal fusion and rod placement Allergic to morphine Pain managed with hydromorphone Presentation Overview Summarize the problem of oversedation Describe strategies to address oversedation Medication risks High risk populations Monitoring Naloxone protocols Roles of an oversedation committee The Challenge OVER-treated Oversedation Respiratory depression Death $$$ UNDER-treated PAIN Delayed healing Increased LOS Poor satisfaction $$$ 2
Opioid-Induced Over Sedation Opioids Mainstay of pain management in hospitalized patients Pain management often suboptimal Generally safe for most patients Respiratory depression most serious adverse event Preceded by sedation Villa, Smith, Augustyniak, Anesthesia & Analgesia 101:474-80, 2005. Incidence Opioids frequently associated with adverse drug events British study 3,695 inpatient adverse drug events 16% attributable to opioids Post-operative respiratory depression Estimated at 0.5% Davies et al., PlosONE, 49(2): 221-7, 20009; Wright et al., AJHSP 69:221-7, 2012. Patient-Related Risk Factors Very young age Older age Sleep apnea Obesity Comorbidities Patients receiving other central nervous system and respiratory depressants Jarzna, et al., Pain Mgt Nurs, 12(3), 118-145, 2011; Dahan, et al., Anesth, 112:226-38, 2010; AGS, J Am Ger Soc, 15:1331-46, 2009. 3
Health Care Related Factors Lack of knowledge Improper prescribing and administration Hydromorphone Morphine Codeine Methadone Transdermal fentanyl Multiple opioids and administration routes Drug-drug interactions Benzodiazepines Phenothiazines Cardiac medications Inadequate monitoring of patients on opioids MULTIFACTORIAL! Jarzna, et al., Pain Mgt Nurs, 12(3), 118-145, 2011; Dahan, et al., Anesth, 112:226-38, 2010; AGS, J Am Ger Soc, 15:1331-46, 2009. Opioid-Related Adverse Drug Events JCAHO Sentinel Event Database (2004-2011) 47% wrong dose 29% improper monitoring 11% other factors Excessive dosing Medication interactions Adverse drug reactions Over Sedation Timeline Research Study HM Alerts Sleep Apnea Morphine Alerts PRN Program HM = hydromorphone PRN = Pain Resource Nurse 4
Predictors of Opioid-Induced Over Sedation in Hospitalized Patients Nursing Research Study Guided Work 4 nurse investigators Pharmacist Purpose: Determine whether 1) individual characteristics, 2) comorbid characteristics and, 3) concurrent medication use predicted over sedation. Lead to the development of risk assessment tools IRB approved Database established of every over sedation in the organization Tracked naloxone dispense reports Included as an over sedation with a clinical response to naloxone Predictors of Over Sedation: Preliminary Results Over 150 cases reviewed 75 cases included Randomized control cases currently being included to develop a predictive model Qualitative review of cases provided insight into trends Descriptive Analysis 67% female 63 mean age 20% American Indian 63% surgical cases Day 2 most common 20% untreated sleep apnea Codeine Converted to morphine via isoenzyme p450 2D6 Poor versus ultra-rapid metabolizers FDA warnings and recent report of 3 home deaths Friedrichsdorf & Nugent, et al. (2013). J Opioid Manage 9(2): 151-155. 5
High Risk Opioids Transdermal fentanyl Black box warning not to use on opioid naïve patients 25 mcg approx = 60 mg oral morphine/day Onset 12 hours Peak 24-48 hours Steady state 5 days Methadone 30% of opioid-related deeaths Should only be used by experienced providers Up to 20x more potent than morphine http://www.cdc.gov/vitalsigns/methadoneoverdoses/ Hydromorphone Dose Limits Hydromorphone is a potent opioid Providers may underestimate its potency 10 mg IV morphine = 1.5 mg hydromorphone Identified as a root cause through a research study Doses > 1 mg IV triggers a dose alert Pharmacist calls provider to clarify Reviews potency with provider 6
Over Sedation Timeline HM Alerts HM = hydromorphone PRN = Pain Resource Nurse Morphine Metabolites Morphine-3-glucuronide (M3G) conjugation accounts for over 50% antagonizes analgesic effect of morphine and M6G Paradoxical neuroexcitatory effects Morphine-6-glucuronide (M6G) conjugation accounts for over 5% more potent analgesic activity than morphine contributes to overall analgesic effect Renal Alert Retention of metabolites with renal compromise No dose is safe Morphine Renal Dose Alert 7
Over Sedation Timeline Morphine Alerts HM = hydromorphone PRN = Pain Resource Nurse Refining Processes for High Risk Patient Populations Health Care, Education and Research www.billingsclinic.com High Risk Populations Obstructive Sleep Apnea Patient Controlled Analgesia 8
Obstructive Sleep Apnea Team The Bulldogs Team initiated in 2011 OSA is characterized by Repetitive episodes of upper airway during sleep resulting in oxygen desaturation & arousals during sleep It is estimated that nearly 80% of men and 93% of women with moderate to severe sleep apnea are undiagnosed Headlines The prototypical OSA malpractice case is finding a postoperative patient dead in bed. UC San Diego School of Medicine (2010). Perioperative management of OSA patients: Practical solutions and care strategies. Retrieved from: http://cme.ucsd.edu/osaonline/osa%20monograph_web.pdf 9
Why is it important during hospitalization? OSA may be exacerbated by effects of anesthetics, opioids, and other CNS depressant medications These medications can: Reduce muscle tone in the upper airway increasing the propensity for airway collapse Increase threshold for hypoxia and hypercapnia & Increase arousal threshold Increase episodes & duration of hypoxemic events in the patient with sleep apnea Identifying & treating patients with OSA is an important steps in preventing complications during hospitalized. Chung, F. and Elsaid, H. (2009). Screening for Obstructive Sleep Apnea Before Surgery: Why is it Important? Current Opinion in Anaesthesiology 22, 405 411. Case Study Patient Information 68 year old S/P Right TKA Admitted post-op @ 10:12 Patient History Sleep apnea Comment: CPAP CPAP not ordered on admission BMI: 34 Kidney disease (not noted in H & P) Creatinine 1.5 Normal 0.6-1.1 Previous hospitalization for surgery Over-sedation event (obtained from patient interview post-event) Event Oxygen Desaturation (untreated OSA) Date & Time Oxygen Saturation O2 Liter Flow O2 Delivery Method Interventions 3/14/11 15:00 92% 1 L Nasal Cannula 3/14/11 18:44 91% 2 L Nasal Cannula 3/14/11 22:23 70% 1 L Nasal Cannula MD notified & order for CXR obtained. 3/14/11 22:24 85% 4 L Nasal Cannula 3/14/11 22:26 87% 5 L Nasal Cannula 3/14/11 22:29 92% 5 L Nasal Cannula 3/14/11 23:21 95% 5 L Nasal Cannula 3/15/11 00:21 93% 5 L Nasal Cannula 3/15/11 00:42 91% 6 L CPAP Applied home CPAP; no order found. 3/15/11 01:15 93% 6 L CPAP 10
Standards of Care for Patients Diagnosed with Sleep Apnea Pre-Admission Testing Patients educated on importance of CPAP use during hospitalization and/or while receiving opioids Asked to bring in CPAP device Intra-Operative Anesthesia uses opioid sparing techniques Post-Op Extended recovery / Education handouts for Outpatients CPAP follows patient to PACU for use as needed Developed CPAP orders for ordering use of home device Apply continuous electronic monitoring for inpatients on opioids Additional interventions: Positioning, notification of provider for apnea episodes STOP-Bang Screening House-wide screening to identify patients with undiagnosed OSA Score displayed on patient summary Moderate to High Risk Patients New CPAP orders developed Use for patients with obvious sleep apnea not previously using CPAP Pressure protocols for Respiratory Therapy to adjust CPAP Notification to PCP for consideration of sleep screen after hospital discharge 11
Patient Controlled Analgesia (PCA) Task Force Team formed June 2009 Goal Implement evidence and literature based standard of care for safe and effective pain management using the analgesic pump Why PCA pump medication delivery is a high-risk treatment that is associated with harmful events and deaths Over Sedation Timeline Sleep Apnea HM = hydromorphone PRN = Pain Resource Nurse Background US Pharmacopeia (USP) medication error databases revealed a combined total of 6,069 PCA errors. 460 resulted in fatality or some level of harm to the patient Review of PCA practice in a hospital with 9,000 PCA patients per year revealed 56 PCA-related adverse events. 71% resulted from PCA programming errors 1. The Joint Commission, Patient Controlled Analgesia by Proxy. Sentinel Event Alert!; 2004, December 20 (33). 12
Standardized PCA Order Sets Reduces Likelihood of ordering error Incidence of respiratory depression Standard order sets Guide drug selection, doses, and lockout periods Patient monitoring 1. Institute for Safe Medication Practices. How to prevent errors - Safety issues with patient-controlled analgesia - Part II. ISMP Medication Safety Alert! July 24, 2003. 2. Weber LM; Ghafoor VL; Phelps P. Implementation of standard order sets for patient-controlled analgesia. Am J Health Syst Pharm. 2008 Jun 15; Vol. 65 (12), pp.1184-91. Patient Monitoring with PCA Monitoring standards part of order set Reminders for assessment frequency appear on the nursing task-list Additional Safeguards Independent double check required for: Initiation Cartridge change Programming changes (e.g., dose, rate, time, etc.) Whenever RN patient assignment changes Minimum of every 12 hours Implementation of smart pump technology 11 near misses (programming errors) caught with use of drug library hard / soft limits in the first 60 days after go-live 13
Nurse Controlled Analgesia Option when patient not appropriate for PCA Only the authorized agent can push the button and this is the nurse caring for the patient Monitoring Hospitalized Patients Receiving Opioids Health Care, Education and Research www.billingsclinic.com Monitoring Standards Based on Opioid Pharmacokinetics Route of Opioid Administration Frequency for Monitoring: Respiratory rate / quality Sedation level Oral or rectal Baseline with first dose With each subsequent dose 60 minutes after administration Every 4 hours Intermittent IV Push, Baseline with first dose subcutaneous, or intramuscular With each subsequent dose 30 minutes after administration Continuous IV Infusion Baseline at initiation (includes PCA with basal infusion) 30 minutes after initiation Every 2 hours x 24 hours, then every 4 hours & PRN Patient Controlled Analgesia, Nurse Controlled Analgesia Baseline at initiation Every 2 hours for first 12 hours after initiation, then Every 4 hours until discontinued Epidural Baseline, then every 5 min x 4 Every 1 hr x 12 hours Every 2 hrs x 12 hours Every 4 hours until discontinued Duramorph Intrathecal Every 1 hr x 12 hours Every 2 hrs x 12 hours Transdermal Baseline Q 12 hours with patch shift checks At dose increase 14
Continuous Electronic Monitoring for High-Risk Therapies Apply continuous pulse oximetry for patients receiving Continuous IV opioid infusion Intravenous Patient Controlled Analgesia Epidural opioids Duramorph Intrathecal (first 24 hours) Next Steps in Monitoring Capnography for patients on oxygen therapy Implementation: October 24 th, 2013 Oversedation Team Expertise Anesthesiology Nursing Pharmacy Meet monthly Examine trends, root cause of oversedations Report to Patient Safety Committee 15
Looking Ahead Current State Prospective review Hourly Narcan Report Rounding and Follow-up? Acute Pain Pharmacist Future State Capnography equipment Acute Pain Team Interdisciplinary Continued education Certified Pain Educator Pain Newsletter Pain Resource Nurses QUESTIONS? oversedationteam@billingsclinic.org Health Care, Education and Research www.billingsclinic.com 16